Summary The Piper PA-31-350 Chieftain (registration C-GNAY, serial number 31-8052095) departed from its home base at Vancouver, British Columbia, with two crew members on board. The aircraft was being repositioned to Powell River (a 30-minute flight) to commence a freight collection route. On arriving at Powell River, the crew joined the circuit straight-in to a right downwind for a visual approach to Runway09. A weather system was passing through the area at the same time and the actual local winds were shifting from light southwesterly to gusty conditions (11to 37knots) from the northwest. The aircraft was lower and faster than normal during final approach, and it was not aligned with the runway. The crew completed an overshoot and set up for a second approach to the same runway. On the second approach, at about 1639 Pacific standard time, the aircraft touched down at least halfway down the wet runway and began to hydroplane. At some point after the touchdown, engine power was added in an unsuccessful attempt to abort the landing and carry out an overshoot. The aircraft overran the end of the runway and crashed into an unprepared area within the airport property. The pilot-in-command suffered serious injuries and the first officer was fatally injured. A local resident called 911and reported the accident shortly after it occurred. The pilot-in-command was attended by paramedics and eventually removed from the wreckage with the assistance of local firefighters. The aircraft was destroyed, but there was no fire. The ELT (emergency locator transmitter) was automatically activated, but the signal was weak and was not detected by the search and rescue satellite. Ce rapport est galement disponible en franais. Other Factual Information Accident Site Examination During the crash sequence, the aircraft went beyond the runway end lights, across 54m of asphalt surface and then 9m of grass surface before going over the edge of a three-metre-high embankment. After overrunning the embankment, the aircraft contacted the upper portion of a deer fence that stood near the same height as the runway elevation. After hitting the fence, the aircraft contacted a dirt berm, bounced back into the air and came to rest in a flat field about 113m from the runway end lights. No tire marks were observed on the asphalt surface of the runway. However, both main landing gear tires exhibited damage consistent with rubber-reversion caused by hydroplaning. Tracks left on the grass by the main gear were consistent with initial braking action that later turned into a skid. No nose gear tracks were found from the point where the aircraft left the asphalt surface to the point where it overran the embankment. Switch positions found in the cockpit were consistent with the crew having completed the pre landing checklist, except that the engine power controls were set for take-off power and the landing gear selector was in the up position. The wing flap selector was found in the up position, and the position of the flap jack screws confirmed that the flaps were fully retracted at impact. Wing flaps are not required to be used for take-off or landing. The left main gear was found extended; however, the down-lock was not engaged, and the gear leg was free to swing freely into the retracted position. The right main gear had been extended at impact and had broken rearward. Damage to the exterior of the nose wheel doors confirmed that the nose wheel was fully retracted and the nose gear doors were closed when the aircraft struck the berm. Both main gear wheel cover doors had been open at impact and were detached from the wings. Examination of the landing gear operating system confirmed that these doors are normally closed except when a gear selection has been made and the landing gear is in transition. Safety features of the landing gear system require that a micro-switch on the left main gear be disengaged by oleo extension before a gear-up selection can be made, and the gear selection lever must be pulled to bypass a projecting safety arm to change positions. For the micro-switch on the left main gear to be disengaged, the aircraft had to be light on the wheels or bouncing when the selection was made. The left-side airspeed indicator (ASI) showed about 74knots and the right-side ASI showed about 67knots. According to the speed range arcs on the ASIs, the aircraft stall speed is 71knots with zero flaps and 67knots with full flaps. According to the pilot operating handbook (POH), the approximate stall speed for the aircraft at its accident weight with a zero flap setting and idle power is 71knots. Scoring and abrasion to the propeller blades in the circumferential direction, as well as bending about the mid-length, were consistent with brief tip contact and a high power setting at impact. Subsequent disassembly and examination of the wheel brake assemblies did not reveal any anomalies. During the wreckage examination, the emergency locator transmitter (ELT) was reconnected to the aircraft antenna and transmitted a strong signal. Airport Runway 09 at the Powell River Airport is 1106 m (3627 feet) long and meets the design criteria specified in Transport Canada's publication TP312 (Aerodrome Standards and Recommended Practices). The embankment, which lies 63m beyond the end of Runway09, is located outside the area of the runway strip-end (overrun area) and does not fall under any airport guidelines regarding surface preparation. A review of recent audits by Transport Canada did not reveal any outstanding issues with the airport that would have contributed to this accident. Airport information published in both the Canada Flight Supplement (CFS) and Canada Air Pilot (CAP) indicates that the slope for Runway09 is 2percent up. A NOTAM (notice to airmen) was issued on 10November2004 to advise that the slope is 1.5percentup. Although the Powell River Airport has a published mandatory frequency, no ground station is in operation, and no airport advisory service is available. The recommended arrival procedure at uncontrolled airports without an advisory service is to overfly the airport before joining the circuit to determine the runway in use, runway condition and traffic. Aircraft The aircraft was configured for cargo operations and was empty at the time of the accident. It was within its certificated weight limits. The aircraft was not equipped with a cockpit voice recorder or a flight data recorder. This equipment was not required by regulation. This particular aircraft was restricted to operating under visual flight rules (VFR) because of a deferred defect recorded in the aircraft journey log, which listed the automatic direction finder (ADF) as unreliable. This defect was noted on a placard mounted on the instrument panel. A review of the technical records and examination of the wreckage did not reveal any outstanding defects that could have contributed to this accident. The aircraft was equipped with a panel-mounted global positioning system (GPS) navigation unit that was examined by the TSB Engineering Laboratory; no meaningful information was recovered. According to the Piper PA-31-350 POH, under conditions of a level and dry asphalt runway, full flaps, approach speed of 95knots, and a 10-knot tailwind, the aircraft should be capable of stopping in about 960feet of ground roll with maximum braking. If an aircraft landed halfway down the runway, there would be about 1814feet remaining plus an additional 207feet before the embankment. Flight Crew The pilots had worked together for the two days previous to the accident. The third day before the occurrence had been a day off for both. Records for the previous two days indicated that daily duty times were within accepted limits. Duty time for the last seven days was approximately 65hours for both pilots. This was the third flight of the day. The captain had been employed with Orca Airways Ltd. since November2005. He held a Canadian commercial pilot licence with an aviation medical valid until 01June2006. He had completed a pilot proficiency check (PPC) on the Piper Chieftain aircraft and had a valid Group1 instrument rating. During previous employment, he had flown this same route and aircraft as a first officer for another operator. He was upgraded to captain when he was hired by Orca Airways Ltd. His total flight time was 1200hours. The captain had received training on pilot decision making, crew resource management and multi-crew operations. The first officer had been employed with Orca Airways Ltd. since February2006. He held a Canadian commercial pilot licence with an aviation medical valid until 01July2006, a Group1 instrument rating and a PPCon the Piper Chieftain. He also had previous experience on the Piper Chieftain aircraft and a total flight time of 500hours. Meteorological Information The weather forecast for the region called for instrument or marginal visual meteorological conditions throughout the day. The main weather systems influencing the region included the passage of a warm front followed by a cold front, both approaching from the west. The winds ahead of the cold front were from the southeast at 30knots and were expected to veer to the northwest at 25knots with the passage of the cold front. Moderate to severe turbulence was expected in the area from the surface to 3000feet above sea level (asl). A pre-flight weather package, printed at about 0500Pacific standard time,1 was retrieved from the wreckage. This package included hourly reports (METARs), significant weather forecasts, terminal area forecasts (TAFs) where available, pilot reports, graphical area forecasts (GFAs), forecast upper winds, and NOTAMs (notices to airmen). The GFA found in the wreckage was valid at 0400. Based on the 0400 information, the cold front was expected to be in the vicinity of Powell River by about 1400. An updated version of the GFA (valid at1000) forecast the cold front to be in the vicinity of Comox (18nm southwest of Powell River) by about 1300and, at the speed it was moving, it was expected to pass Powell River in another hour. It is unknown whether the crew had received this information. Communication records for the Kamloops Flight Information Centre (FIC) indicated that the crew had obtained weather updates by telephone throughout the day and had obtained their last weather briefing by telephone shortly after 1500 (about 45minutes before departing Vancouver for Powell River). During that briefing, there were no specific questions asked about the location or speed of the approaching cold front, but, at that time, the TAF for Comox indicated that the change in wind direction associated with the cold front passage at Comox was forecast to occur between 1400and1600. The 1500 METAR indicated that the wind in Comox had shifted to the southwest. Although not discussed by telephone, a significant weather report (Sigmet L6) had been issued at 1510to advise of continued severe turbulence below 3000feetasl due to a low-level jet stream. Communication records for all air traffic control (ATC) facilities involved with the flight, and any that may have been contacted en route, were reviewed and it was concluded that the crew neither requested nor received any updated weather information after their telephone briefing at1513. The weather observation station at the Powell River Airport is a contracted service and was staffed at the time of the accident. The weather station provided regular hourly reports, and special observations for limited hours. The weather station contract does not include the provision of an airport advisory service, and there is no regulatory requirement for airport advisory services to be provided. TAFs are not produced for the Powell River Airport but are available for Comox. Throughout the day, the wind at Powell River had been consistently from the east at speeds from 24knots and gusting as high as 50 knots. The weather report for 1600, about 40minutes before the accident, reported that the wind had calmed down to 120magnetic(M) at 6knots. However, weather changes associated with the cold front passage over the 15-minute period preceding the accident resulted in the on-site weather station issuing two special observations. The first, at 1622, reported the wind to be 120M at 8knots, the visibility reduced from 10to 6statute miles (sm) and light rain had become light rain showers and mist. The second special report issued at 1628 (six minutes before the first approach) reported a change in the wind to 200M at 10knots, visibility reduced to 4sm in light rain showers and ice pellets. Both special observations also reported towering cumulus clouds embedded. The latest special observation was followed immediately by a correction that changed the intensity of the rain showers and ice pellets from light to moderate. Subsequent to the 1628special report, the winds in Powell River shifted from light southwesterly to gusty conditions (11to 37knots) from the northwest. The weather observation station personnel were in the process of taking another wind reading when the accident occurred. Survival Aspects Both pilot seat frames were deformed from the force of impact. Damage to the right-hand seat was more extensive as was damage to the floor structure below it. Both seats were equipped with lap belt, single diagonal shoulder strap, and inertia reels. Both pilots wore all restraints. Since both pilots suffered injuries, both shoulder strap inertia reels were sent to the TSB Engineering Laboratory for examination. These components showed signs of minor damage, which was determined to have resulted from the loads applied during impact. Despite this damage, both inertia reels were found to be in working order. A manufacturer's Alert Service Bulletin (SB), A25-1124A, dated 01June2000, was applicable to both inertia reels, but had not been implemented. The SBrecommended replacing the inertia reel aluminum shaft with a steel shaft to prevent premature failure due to wear contact with another part. Non-completion of this SBresulted in the risk of failure increasing over time, but was not a contributing factor in this accident. Completing the maintenance action recommended in an Alert Service Bulletin is not mandatory. The autopsy examination attributed the fatality to a pattern of injury most often associated with a vertical force. It was likely that the initial impact with the dirt berm caused the fatal injuries to the first officer. The nose section of the aircraft did not contact the dirt berm but was substantially damaged in the second impact, and this is most likely when the feet and ankle injuries occurred.